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Updated 02 August 2017

Why patients leave the hospital against doctor's orders

Patients' age, gender, ethnicity, mental health and medical cover are all factors that influence their likelihood of discharging themselves from hospital.

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Let's face it, it's not much fun in hospital – the food isn't home-cooked and you miss your family. It's therefore not uncommon that patients discharge themselves from the hospital against their doctor's advice.

These are however not the only reasons, and new research on over 29 million hospital stays has shed light on which types of patients are most prone to this behaviour – and why.

Using 2013 US hospital data, researchers found that younger patients are much more likely than older patients to leave the hospital against the advice of their doctor.

In fact, patients aged 65 and older were four times less likely to leave the hospital against medical advice than adults under 65, according to a team led by Dr Jashvant Poeran, of the Icahn School of Medicine at Mount Sinai in New York City.

There are unfortunately no South African statistics to indicate how many patients prematurely discharge themselves from hospital. 

Many influencing factors

Other factors played a role as well. Regardless of their age, men were more likely to to leave the hospital against medical advice than were women, the study found. A lack of insurance, being covered by Medicaid, and the presence of a mental health disorder also raised the risk.

In South Africa medical inflation is very high, and especially older people find it difficult to afford medical aid contributions – many ending up without insurance.

And among older patients, the risk of leaving the hospital against medical advice was 65% higher for blacks and 57% higher for those with low incomes, the researchers noted.

Incidents like these are on the rise, Poeran's team added. Between 2003 and 2013, rates of unadvised self-discharge for adults under 65 rose from about 1.4% of all patient stays to nearly 1.8%, the team said.

Suboptimal communication

And the consequences of such actions – for patient well-being and the health care system – can be dire. According to the researchers, leaving the hospital against a doctor's orders is linked to a higher risk of hospital readmission, illness and death, as well as increased costs.

People hospitalised for heart failure are being discharged faster, but the incidence of out-of-hospital deaths and readmissions has increased correspondingly, according to a study.

The study was published in the Journal of the American Geriatrics Society.

"One of the reasons mentioned in previous studies for leaving the hospital against medical advice is suboptimal communication, which may indeed affect older minority patients more," Poeran said in a journal news release.

Dr Liron Sinvani directs the Geriatric Hospitalist Service at Northwell Health in Manhasset, New York. She agreed with Poeran that, "a person's decision to leave the hospital against the advice of his or her care provider often represents a breakdown in communication between patients, family members and providers".

She said the study "highlights the significance of communication between the patient and the care team".

Coverage decisions

Discharging oneself from the hospital against a doctor's orders can have legal ramifications, too, said Michael Duffy.

He's a personal injury attorney and expert in malpractice law practicing in Uniondale, New York.

Duffy believes patients often feel pressure to discharge themselves from care because of coverage decisions made by their insurance company.

"We cannot allow insurance companies and hospital bean counters to determine when a patient is discharged," Duffy said. "It is immoral for those who concern themselves only with the bottom line to overrule and contradict the expertise of health care providers."

Poeran added: "More research is needed to find out why exactly race/ethnicity and poverty are more pronounced as risk factors in older patients, especially since Medicare theoretically offers universal health coverage for patients aged 65 years or older".

Read more:

Heading for hospital?

12 scary hospital stats

Follow-up keeps high-risk patients out of hospital

 
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